For discussion and debate about the ethics of health care organizations and the wider health system.

Saturday, June 20, 2009

The Ethics of an Individual Mandate

It's looking more and more as if the health reform legislation that the President wants to see emerging from Congress this summer will include a requirement that individuals obtain health insurance, just as the states currently require car owners to obtain insurance for their vehicles.

If health care were a consumer good a requirement for insurance could not be justified. Having a car is desirable, but it's optional. If poor people can't afford a car we regard that as unfortunate, but not unjust. But if a poor person is dying from a curable cancer we believe, correctly, that a society as wealthy as the U.S. is obligated to ensure access to treatment. The Declaration of Independence declares a right to "life, liberty, and the pursuit of happiness." We require ourselves, correctly, to provide public education, because lack of literacy and numeracy impedes liberty and the pursuit of our goals. Basic health care is at least as necessary for us to exercise our freedom in a meaningful way.

One reason our health insurance system works so badly is that so many Americans are not in it. This creates a vicious circle. Rational economic behavior suggests that we should not buy insurance when we are and expect to remain healthy, but should rush to get it when we're sick. Insurers must protect themselves against this form of "adverse" selection by establishing underwriting rules, such as not covering preexisting conditions, and charging more for people who are ill. This results in more people being uninsured, including many for whom access to insurance is most important.

The simplest way to bring everyone into the health system is to fund insurance through taxes. We currently have two major tax supported insurance systems - Medicare and Medicaid. Taxes could be used to support a single public insurance program ("single payer") or a market of private plans, as envisioned in Zeke Emanuel's 2008 book "Healthcare Guaranteed."

It's telling that even though Zeke Emanuel's plan retains the private insurance market, his brother Rahm, President Obama's Chief of Staff, has called it "wacko." I believe Rahm the politician called his ethicist brother "wacko" because Zeke correctly suggests that health insurance must have a capped budget and that the budget should come from a new dedicated Value Added Tax. Even apart from the current recession taxes are the black hole of American politics - any leader who proposes a tax disappears into a void.

If (a) the insured population must include everyone to be actuarially and ethically sound but (b) tax funding is off the table (at least for now), then (c) the individual mandate is the only other route to universality. That's what an article - "The Individual Mandate — An Affordable and Fair Approach to Achieving Universal Coverage" in this week's New England Journal of Medicine argues. A mandate is klunky to administer and will require subsidies for low income folk. But if U.S. political culture forbids an openly tax financed system, the individual mandate is the politically viable and ethically acceptable way to go.

John Donne's communitarian moral outlook sounds too much like "socialized medicine" to play a major role in the U.S. health reform debate, but it should:

No man is an island entire of itself; every manis a piece of the continent, a part of the main; if a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as any manner of thy friends or of thine own were; any man's death diminishes me, because I am involved in mankind. And therefore never send to know for whom the bell tolls; it tolls for thee.

I would rather hear social solidarity arguments for why our health system should be inclusive. But the individual mandate, which takes the route of telling each of us that we can't be slackers and must take responsibility for paying our own way in the health system (unless we're poor enough to warrant a subsidy), gets us to the same place on the back of individual responsibility. This appears to fit our political culture better than a more communitarian ethic.

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About Me

I've been in health care for 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs and ACOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

In the blog I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings. Although organizational ethics is my main focus, I also write about other ethical issues that interest me.